1790136414 NPI number — FIVE STAR INDUSTRIES, INC.

Table of content: DR. KOREY BENJAMIN KASPER M.D. (NPI 1669854618)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790136414 NPI number — FIVE STAR INDUSTRIES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FIVE STAR INDUSTRIES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790136414
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/23/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 60
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DU QUOIN
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62832-0060
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
618-542-5421
Provider Business Mailing Address Fax Number:
618-790-9147

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1308 WELLS STREET RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DU QUOIN
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62832-4171
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
618-542-5421
Provider Business Practice Location Address Fax Number:
618-790-9147
Provider Enumeration Date:
06/23/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
ENGELHARDT
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
618-542-5421

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320900000X , with the licence number: 199100056S , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)